Healing Minds Therapeutic Services, PLLC: Registration Paperwork

SIGNED INFORMED CONSENT FOR PARTICIPATION IN ASSESSMENT & TREATMENT

On behalf of myself, or client if a minor, I hereby agree to the following conditions of participation in assessment and treatment:

 

1.       Voluntary Participation: I voluntarily consent to participate in such counseling services as may be deemed necessary and appropriate by the staff of Healing Minds Therapeutic Services, PLLC.  I understand that I will be kept informed of plans for my treatment and may withdraw my consent in writing at any time.  I am aware that the practice of counseling is not an exact science and I acknowledge that no guarantees have been made as to the effectiveness of the treatments and assessments.

 

2.       Confidentiality: I give permission for the office staff of Healing Minds Therapeutic Services, PLLC to provide clinical information to my insurance or its designee at their request, for the purpose of justifying my need for treatment and/or continued treatment.  Other verbal and written information regarding my treatment is protected by Federal law and regulations and may be released only with my specific written consent to qualified personnel for research, audit or evaluation purposes, or when the opinion of clinical staff deem there is a medical emergency and release of information would in my behalf, aid in my treatment, or protect the safety of myself and/or others by court order.  Suspected violations may be reported to appropriate authorities in accordance with Federal regulations.  Federal law and regulations do not protect any information about a crime committed by a client either at the program, or against any person who works for the program, or about any threat to commit a crime.  Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under State law to appropriate State and local authorities. 

 

Follow-Up Protocol: I agree that the office staff members of Healing Minds Therapeutic Services, PLLC may call or write if I fail to keep an appointment in order to assess my need for further treatment.  I also agree the office staff members of Healing Minds Therapeutic Services, PLLC may contact me via letter after I have completed treatment in order to obtain information about the quality and effectiveness of the services, I received at Healing Minds Therapeutic Services, PLLC.

HIPAA Privacy Rules: Protection of Health and Mental Health Information

(45 CFR Parts 160 and 164)

 The information provided below is a summary and intended for general information purposes.  Information on HIPAA is also found in our Consumer’s Rights Handbook, which can be found at the front desk.  You can request a copy of this notice and/or the Consumer’s Right’s Handbook upon request.

 The HIPAA Privacy Rule (45 CFR Parts 160 and 164- (164.524; 164.528; 164.508; 164.512a) provides the first comprehensive Federal Protection for the privacy of health and mental health information.  The rule is intended to provide strong legal protections to ensure the privacy of the individual health information and mental health information, without interfering with the patients access to treatment, health care operations, or quality of care.  The Privacy Rule applies to ‘covered entities’ which generally includes health plans and health care providers who transmit health information in electronic form.  Covered entities include almost all health and mental care providers, whether they are outpatient, residential or inpatient providers, as well as other persons or organizations that bill or are paid for health care.

 ” Minimum Necessary” Rule:

A covered entity must make responsible efforts to use, request, or disclose to others only the minimum amount of Protected Health Information (or PHI) which is needed to accomplish the intended purpose of use, request or disclosure.  When the minimum necessary standard applies, a covered entity may not use, disclose, or request a person’s entire medical record unless it can be specifically justified that the entire record is reasonably needed.  The minimum necessary standard does not apply under the following circumstances:

 a.       Disclosure to a healthcare provider for treatment;

b.       Disclosure to an individual (or personal representative) who is the subject of the information;

c.       Use or disclose made pursuant to an Authorization by the person (or personal representative);

d.       Use or disclosure that is required by law; or

e.       Disclosure to Health and Human Services (or HHS) for investigation, compliance

 Basic Principles of the Privacy Rule:

 1.       The Privacy Rule protects all ‘protected health information (PHI),’ including individuality identifiable health or mental health information held or transmitted by a covered entity in any format, including electronic, paper, or oral statements.

a.       A major purpose of the Privacy Rule is to define and limit the circumstances under which individual’s PHI may be used or disclosed by covered entities.  Generally, a covered entity may not use or disclose PHI to others, except: as the Privacy Rule permits or requires or as authorized by the person (or personal representative) who is the subject of the health information.  A HIPAA-compliant Authorization must contain specific information required by the Privacy Rules.

2.       A covered entity must provide individuals (or their personal representatives) with access to their own PHI (unless there are permitted grounds for denial) and must provide an accounting of the disclosures of their PHI to others upon their request. 

3.       The Privacy Rules supersedes State law, but State laws provide greater privacy protections under which give individuals greater access to their own PHI remain in effect.

 Permitted Uses or Disclosures of PHI Without Authorization

1.       A covered entity may disclose PHI to the individual who is the subject of the information.

2.       A covered entity may use and disclose protected health information for its own ‘treatment, payment and health care operations.’

a.       Treatment is the provision, coordination, or management of healthcare and related services for an individual, including consultation between providers and referral of an individual to another provider for health care.

b.       Payment includes activities of a health care provider to obtain payment or receive reimbursement of the provision of health care to an individual.

c.       Health care operations include functions such as: (a) quality assessment and improvement; (b) competency assessment, including performance evaluation, credentialing, and accreditation; (c) medical reviews, audits, or legal services; (d) specified insurance functions; and (e) business planning, management, and general administration.

3.       Permission may be obtained from the individual who is the subject of the information or by circumstances that clearly indicate an individual with the mental capacity can object to the disclosure but does not express an objection.  Providers may also rely an individual’s informal permission to disclose health information to an individual’s family, relatives, close personal friends or to other persons identified by the individual, limited to the information directly related to such person’s involvement. 

4.       When an individual is incapacitated or in an emergency, providers sometimes may use or disclose PHI, without authorization, when it is in the best interests of the individual.  Such as determined by health care providers in the exercise of clinical judgment.  The PHI that may be disclosed under this provision includes the patients name, location in a health care providers facility, and limited and general information regarding the person’s condition. 

5.       Providers may use or disclose PHI without a person’s authorization when the disclosure of PHI is required by law, including State statute or court order.

6.       Providers generally may disclose to State and Federal public health authorities to prevent or control, injury, or disability, and to government authorities authorized to receive reports on child abuse and neglect. 

7.       Providers may disclose PHI to appropriate government authorities in limited circumstances regarding victims of abuse, neglect, or domestic violence.

8.       Providers may disclose PHI to health oversight agencies, (e.g.., the government agency which licenses a provider), for legally authorized health oversight activities, such as audits and investigations.

9.       PHI may be disclosed in a judicial or administrative proceeding if the request is pursuant of court order, subpoena, or other lawful process (Note: the ‘more stringent’ NYS Mental Hygiene Law requires a court order for the disclosure of mental health information in these circumstances).

10.   Providers may generally disclose PHI to law enforcement when:

a.       Required by law, or pursuant to a court order, subpoena, or an “administrative request,’ such as a subpoena or summons (Note: the ‘more stringent’ NYS Mental Hygiene Law Section 33.13 requires court order for the disclosure of MHI in these circumstances).

b.       In response to a law enforcement request for information about a victim of a crime (Note: under Mental Hygiene Law Section 33.13 this information is limited to “identifying data concerning hospitalization.”

c.       To alert law enforcement about criminal conduct on the premises of a HIPAA covered entity.

d.       Providers may disclose PHI that they believe necessary to prevent or lessen a serious and imminent physical threat to a person or the public, when such disclosure is made to someone they believe can prevent or lessen the threat (including the target of the threat).

e.       Programs involved in the sharing of information is required or expressly authorized by statute or regulation, or other limited circumstances.

 Complaints to: Office for Civil Rights Department of Health and Human Services, Atlanta Federal Center, Suite 3B70 61 Forsyth Street, S.W. Atlanta, GA 30303-8909.  Web site at: https://www.hhs.gov/hipaa/filing-a-complaint/index.html?language=es

 I HAVE READ AND UNDERSTAND MY RIGHTS UNDER THE HIPAA GUIDELINES.

Fees for Services Performed Outside of Counseling

 Payment for services at Healing Minds Therapeutic Services, PLLC are due when services are provided.  As a courtesy to our clients and families, we will bill your insurance company in accordance with the information you provide to us.  It is your responsibility to keep Healing Minds Therapeutic Services, PLLC staff informed of any changes to your insurance coverage.  You are obligated to pay and deductible or copay required under your insurance plan, at the time of service.

 Charges are based on the type of services provided to you.  If additional time or services, (such as telephone sessions or reports) are provided, a pro-rated fee will be charged.  You remain legally responsible for all charges.

 Below is a list of common services and fees that clients may encounter.  Your provider will discuss these fees with you at the time of the request.

 Letters/Reports for your insurance company or another agency
$150 per hour

Court related costs: letters, testimony, forensic reports, etc.  (Costs for testifying include travel time “door-to-door” with 3 hours paid up front.)
$250 per hour

Services that are not covered by your insurance company: (Certain types of testing, phone sessions, etc.)
$150 per hour
 

You will be charged for all missed appointments.  With sufficient notice, an appointment can generally be rescheduled.  Failure to give 24-hour notice of cancellation will result in a ‘NO-SHOW’ charge of $25.00.

 Note: Per CMS rules, Medicaid recipients will not be charged ‘no-show’ fees but will be responsible for other fees contractually agreed to.

 This financial relationship will continue as long as we provide services or until such time as you notify us that you wish to terminate treatment.  Once treatment terminates, any balance not paid in full will be considered due immediately.  When an account becomes 60 days past due, professional collections may be utilized, and/or legal action may be taken. 

 My signature below indicates that I have read and understand this fee policy.  I agree to take full responsibility for fees charged to my account. 

Tele-Health Consent Form

This form is intended to provide information about tele-health visits, which are different form in-person office visits and require separate consent from the patient.

1. Tele-Health uses audio and video technology to enable health care providers to have visits in real time with patients who are not physically present in the office.

2. During a tele-health visit, the information obtained, such as medical history, evaluations, and/or test results will be used for diagnosis, treatment, follow-up and/or education.

3. Consenting to receive tele-health visits does not mean that all future visits will be via tele-health.

4. The provider has the right to determine whether or not any given patient visit is appropriate to be conducted via tele-health. The provider and the patient both have the right to discontinue the visit at any time.

5. The records of tele-health visits will become part of the patient's medical record. All existing laws regarding your access to medical information and records apply to tele-health visits. Sharing of any personal health information to other persons or entities outside of Healing Minds Therapeutic Services, PLLC providers and staff shall not occur without the patient's written consent unless shared for purposes of treatment, practice operations, or billing.

6. There are technology related risks in using tele-health, such as problems with transmission (i.e. low resolution or signal or interruption) and/or deficiencies or failure of equipment. These may interfere with proper evaluation of the patient. In addition, the transmission is encrypted, and other measures have been taken to prevent unauthorized parties from accessing the transmitted information.

7. Please protect your email and passwords, and notify the practice of changes or email address.

8. The tele-health visit will follow the same process for billing and payment for an in-person face-to-face visit and the patient or subscribed may be responsible for all or some of the bill based on insurance coverage.

Consent To The Use of Tele-Health

I have read and understood the information provided above regarding tele-health, including the risks associated with online communication, and all of my questions about tele-health have been answered to my satisfaction. I give my consent for the use of tele-health for my care.

Consumer Acknowledgment of Information Received

 The following is a summary of our Consumer Rights Handbook, which provides important information about your rights as a consumer, notifications of the 24 hour Crisis Coverage Policy, responsibilities/rules to follow and possible penalties for violations, the procedure to obtain a copy of your treatment/service plan, your right to contact Disability Rights NC if you have a complaint, and your right to Protection of Health Information (PHI) covered under HIPAA laws. If you would like to have a copy of the full Consumer Rights Handbook, please let the front desk staff know.

 CONSENT FOR TREATMENT FOR MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES: I voluntarily consent to participate in professional counseling services as may be deemed necessary and appropriate by the clinical staff at this Agency.

 ATTENDANCE/APPOINTMENTS: By signing below, you are indicating you understand that it is your responsibility to keep all scheduled appointments (group, individual, family, team meetings) if possible.  If you are unable to keep your scheduled appointment, you are to make efforts to call this office or your assigned counselor prior to the appointment.  Your counselor will ultimately determine if the cancellation is ‘excused’ or ‘unexcused’.  If you have more than 3 unexcused absences, then you are subject to likely termination from the program and will be discharge as ‘unsuccessful’.  You will be given several other provider resources to contact to continue your care.

HIPAA (NOTICE OF PRIVACY PRACTICE): This Agency is required by the Health Information Portability and Accountability Act (HIPAA) of 1996 to maintain the privacy of your health information as stated in our Notice of HIPAA Privacy Practices.  I acknowledge that I have been informed by the Privacy Practices for this Agency. 

CLIENT RIGHTS AND RESPONSIBILITIES/CODE OF ETHICS: I attest and acknowledge that I have been given a copy of the handbook entitled ‘Consumer Rights Handbook’ for this Agency, and it is to be kept for my personal use.  I have read it, or had it read to me.  My questions regarding my rights have been answered and I understand my rights as a consumer of this Agency.  I understand that the handbook provides information about my rights and responsibilities as a consumer and does not constitute legal advice or findings with respect to those rights and responsibilities and should not be considered as granting or denying any right guaranteed by law.  The ethical guidelines governing the Mental Health Substance Abuse Profession are established to ensure that the highest standards are followed for the professional practice.

 CONFIDENTIALITY:  The confidentiality of patient records maintained by this program is protected by federal law and regulations.  Generally, the program may not say to a person outside the program that a person attends this program, or disclose any information identifying a patient as an alcohol or drug abuser unless the patient consents in writing.  Federal laws require or allow that we can share your health information including alcohol and drug abuse records with others, in specific situations in which you do not have to give consent, authorization or can agree or object to the disclosure.  These situations include, but are not limited to the following: 1) to county DSS or law enforcement to report abuse, neglect or domestic violence; 2) to respond to court order or subpoena; 3) to appropriate authorities if we learn that you might seriously harm another person or property in the future or that you intend to commit a crime of violence or that you intend to self-harm; 4) purpose of internal communications as outlined above; 5) to qualified service organization agencies when appropriate; 6) the disclosure is made to medical personnel in a medical emergency or 7) to qualified personnel for research, audit or program evaluation.  I acknowledge receipt of this notice of confidentiality of my presence in this program and the confidentiality of my records. 

ORIENTATION TO FACILITY & 24-HOUR CRISIS COVERAGE: I acknowledge that I have been made aware of all safety exits, public restrooms and can request assistance if necessary.  I am also aware that I may access this Agency in a crisis situation by calling 910-489-4962.

 FOLLOW-UP: I agree staff members may contact me by telephone or by letter after discharge for the purpose of tracking progress/outcomes. 

I attest that I have been provided information regarding how to file a complaint with the NC DHHS Complaint Hotline: 1-800-624-3004 (within N.C.) or 919-855-4500 or with the Secretary of DHHS at 200 Independence Avenue S. W. Washington, DC 20201 or by calling 877-696-6775.  

Also, complaints can be made by calling the Office of Civil Rights at 800-368-1019 and/or Disability Rights North Carolina at 877-235-4210 to file a complaint regarding Rights of Individuals with Disabilities. 

 My signature below confirms I have reviewed the summary of the Consumer Rights Handbook, which outlines this Agency’s policies and practices as summarized above. If you would like a copy of the Consumer Rights Handbook, please notify the front desk staff.